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Member
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Join Date: Jan 2009
Location: Paradise
Posts: 855
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Member
Join Date: Jan 2009
Location: Paradise
Posts: 855
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Quote:
Originally Posted by Jo*mar
Is anyone having these problems ?
A member is asking on the wc forum.
[Utilization Reviews - Anyone Being Abused?
Everybody:
I need your help. Is anyone being harrassed or abused by multiple filings of Utilization Reviews?
I believe this is California only.
I need people who are being harrassed or retaliated against, and in CA, they are using these URs to delay or end treatment on even the admitted / accepted cases.
Also, they are "doctor shopping" where they send you to one doctor and they don't like the report, so they then send you to more and more.
Is ANYONE else being treated like this? Because, I am contacting the media. ]
the link to the post on wc forum if this applies for you -
http://neurotalk.psychcentral.com/thread117947.html
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It is even more sinister than you think. Prior to 1/1/05 (generally) in CA, the treating Dr was presumbed to be most correct when a med-legal issue arose. And if it became litigated, then the judge would have to error in favor of the patient. Since then the "good book," the ACOEM Guidelines is now the presumption of correctness (that's right, a book, not a person). It is heavily based on the AMA Guidelines for Impairment 5th ed., So if it isn't in the books, forget it, you're not getting it!
UR is a seperate issue. It is now mandated that the insurer must have UR analyse the claim before authorization to treat is given or money paid. All treatment must abide by the insurer/UR's interpretation of the "good books," no exceptions. UR companies have been anywhere from a branch of the insurer (by a different name) or a situation where several UR companies, usually out of state, clamor to the insurer bidding for thier UR services. The lowest bidder (and one who denies the most claims) gets the job. An associated tier of WC in CA has to do with the fact that mostly only MPN (multi-physican network) docs can treat the patient-can't see your own doc. And guess who butters the bread of the MPN doc?
The main reason this was done was because all of the employers were complaining that WC insurance was sooo expensive. So enter the 2005 reform. It cut cost of WC health care by 50%. It also cut the ability to treat a patient by 50% too as treating docs don't get authorized to treat, much, sometimes not at all. Needless to say, it was buyers remorse and there is some desire to revert somewhat back to days when injured workers got fairly treated (NPI). And some of you wanted universal care???
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